Severe bilateral Legg-Calvé-Perthes resolved with pamidronate in combination with casts, physiotherapy and adductor tenotomy: a pictorial essay over 11 years.

We describe an 11-year prospective clinical and radiologic course of a 6-year-old boy with bilateral Legg-Calvé-Perthes disease, who was treated with intravenous pamidronate (IV-PAM). His baseline radiographs showed grade IV avascular necrosis/Catterall stage IV, and at worst he progressed to lateral pillar/Herring stage C bilaterally. His disease initially was extremely functionally limiting with expected poor outcome with eventual joint replacement. Because IV-PAM stops bone breakdown and allows for ongoing bone formation while revascularisation of bone occurs, we hypothesised that IV-PAM could act as an adjunct to traditional treatment to help heal the femoral heads. Our patient received nine once monthly doses of IV-PAM (1 mg/kg/dose) over 13 months, along with Petrie/broomstick casts and physiotherapy. Remarkably, over time, his femoral heads healed. Now, at 11-year follow-up, he has excellent functional and radiologic outcome with congruence between femoral head and acetabulum, no residual osteonecrosis and minimal loss of femoral head sphericity.

Evaluation of physiotherapy in the treatment of Legg-Calvé-Perthes disease.

INTRODUCTION: Physiotherapy using muscle strengthening and stretching exercises is claimed to have beneficial effects in the treatment of Legg-Calvé-Perthes disease; however, no scientific evidence is available concerning effectiveness of treatment. PURPOSE: The purpose of the present study was to clinically evaluate possible effects of the proposed physiotherapeutic effects compared to observational follow-up in patients with Legg-Calvé-Perthes disease. METHOD: A prospective follow-up study was conducted in 17 patients with unilateral Legg-Calvé-Perthes disease, divided into 2 groups: Group A (observational follow-up) and Group B (physiotherapeutic follow-up). In order to evaluate the outcome of the adopted treatments, the following parameters were assessed: articular range of motion, level of muscular strength, level of articular dysfunction, and radiographic status, both before and after the treatment. RESULTS: Group B exhibited significant improvement in articular range of motion concerning hip flexion, extension, abduction, adduction, medial rotation, and lateral rotation, while in Group A an equally significant worsening occurred concerning abduction, adduction, and medial rotation. Muscular strength also improved in Group B, mainly in the set of hip flexor muscles, while Group A showed no changes. Articular dysfunction after therapy compared to pretherapy was significantly reduced in Group B and increased in Group A. Patients undergoing physiotherapy exercises showed no changes in their radiographic features. CONCLUSION: Physiotherapy produced significant improvement in articular range of motion, muscular strength, and articular dysfunction in patients with Legg-Calvé-Perthes disease, but these improvements were not evident on radiographs.

Different methods of treatment related to the bilateral occurrence of Perthes' disease.

We treated 98 consecutive patients with Perthes' disease by a unilateral brace in external rotation, flexion and abduction and a further consecutive 110 by a bilateral cast with the hips in internal rotation and abduction. During treatment in the unilateral brace, six (6.1%) hips on the opposite side developed evidence of Perthes' disease and one developed this after the brace had been removed. In children managed in bilateral casts, no contralateral Perthes' disease was seen. Adequate containment of the femoral head may prevent subsequent changes in the opposite hip.

Preliminary report on usefulness of magnetic resonance imaging for outcome prediction in early-stage Legg-Calvé-Perthes disease.

The usefulness of magnetic resonance imaging (MRI) for predicting prognosis was evaluated in 11 patients with unilateral early-stage Legg-Calvé-Perthes disease who were treated with a non-weight-bearing abduction brace. Six to 10 months after disease onset, severity of cartilage hypertrophy and physeal curvature of the femoral head were scored on MRI. Femoral head deformity was radiographically evaluated. Among five patients whose MRI score was 8 or greater, radiographic evaluation after the treatment was "poor" or "fair," whereas evaluation for the other six patients whose MRI score was 7 or less was "good." The MRI scores indicated possible occurrence of femoral head deformation. Treatment method should be considered carefully when the MRI score is high.

Perthes-like changes in geleophysic dysplasia.

Geleophysic dysplasia is a rare skeletal dysplasia characterised by 'happy natured' facies, short stature with short limbs, brachydactyly, and joint contractures. This report describes a case of a patient with unilateral Legg-Calvé-Perthes-like changes associated with dysplastic proximal capital femoral epiphysis, typical to geleophysic dysplasia.

Evaluation of gait performance of a participant with Perthes disease while walking with and without a Scottish-Rite orthosis.

BACKGROUND: Scottish-Rite orthosis is one of the conservative methods used to treat Legg-Calvé-Perthes disease. As there was not enough evidence to show the effects of using this orthosis on reducing the loads applied on the limb, this research aimed to find the influence of this orthosis. CASE DESCRIPTION AND METHODS: A participant with Perthes disease on the left hip joint was recruited into this study to walk with and without the orthosis. The kinetic and kinematic parameters were collected by a motion analysis system and a Kistler force platform. FINDINGS AND OUTCOMES: No significant differences were noted between the hip joint flexion/extension range of motion and the moments between the sound side and the side affected by Legg-Calvé-Perthes disease. It may be concluded that use of orthosis may not have any positive effects to decrease the loads or to improve the alignment of the hip joint in participants with Perthes disease, as expected. CONCLUSIONS: The use of Scottish-Rite orthosis not only does not improve the containment of the hip joint, but also does not have any significant influence on loads applied on the joint during walking of the subject with Perthes disease. CLINICAL RELEVANCE: The results of this research can be used by clinicians involved in treatment of patients with Legg-Calvé-Perthes disease.

Determination of femoral head containment during gait.

Using three-dimensional gait data, a mathematical model of the proximal femur was developed that will predict the loading conditions in the child's hip joint during walking. The model is based on knowledge of rim coordinates of the acetabulum, and consists of rotating unit vectors emanating from the center of the epiphysis. The results will be used in a variety of three-dimensional stress analyses of the femoral head in Legg-Perthes disease (a disorder of femoral head collapse).

[Splint treatment of Perthes disease]. / Schienenbehandlung bei Morbus Perthes.

In Perthes' disease the necessity of any treatment and its management has to be considered carefully. Good results are reported after treatment with various splints as well as after surgery. According to Imhäuser we prefer a position for the hip joint in the splint in 30 degrees flexion, abduction and external rotation respectively. In this position the lowest intraarticular pressure was measured. If deterioration of the containment develops while using a splint, we recommend surgical treatment.

[A treatment principle with questionable effectiveness in Perthes disease]. / Ein Behandlungsprinzip mit fragwürdiger Wirksamkeit bei Morbus Perthes.

The reduction of hip joint forces is a generally accepted part of the conservative treatment of Perthes disease. To reach this effect with help of splints (e.g. Thomassplint and the following models) does not seem to be efficient enough even from a clinical point of view. Theoretical considerations of former investigations of other authors point out the insufficient effect of these splints regarding the hip joint force reduction during the weight bearing phase in walking. The effect of these splints during the non-weight bearing phase in walking with regard to the hip joint forces has not been investigated so far. Therefore this paper is dealing with the forces onto the hip joint during the swinging phase of the leg with a splint, shown in a simplified, mechanical model. The results reveal significantly higher hip joint forces if the splint is used compared to the physiological forces during the swinging phase which in a static situation rise up to twice the body weight. These joint loadings are important because they occur during hip flexion and therefore cause pressure on the ventro-cranial part of the head of the femur, a region which unfortunately is often involved in Perthes' disease and therefore especially vulnerable to these forces. From a biomechanical point of view the principle of reducing the hip joint forces with splints has to be abandoned.

[Nonoperative treatment in Legg-Calvé-Perthes disease]. / Die nichtoperative Therapie des Morbus Perthes.

There is still discussion about the indication for and modalities about treatment of Perthes'disease. The main objective of treatment in Perthes'disease is prevention of deformation and malalignment of the hip joint. Most important for the evaluation of any therapy is the long term outcome, therefore we present this retrospective study on nonoperative treatment of perthes disease with orthoses compared to the natural history. 54 Patients with 59 involved hips, treated between 1945-1975 were clinically and radiologically evaluated. We divided the patients into two subgroups: Group 1 with nonoperative therapy. Group 2 with no therapy. The outcome shows correlation of the results with the degree of malalignment and necrosis. There was no statistically significant correlation between the two groups, but a slightly better outcome in the non-operative group compared to the natural history. The use of orthosis may be justified if there is improvement of the containment and reduction of the femoral head, otherwise surgical treatment like pelvic- and hip osteotomies to realign the hip joint should be considered.

[Outcome of decompression operations in the treatment of Legg-Perthes disease]. / Iskhody dekompressivnykh operatsii v lechenii bolezni Pertesa.

The authors evaluate the results of 90 decompression operations in 68 patients with Perthes' disease at stages I-IV; the mean age of the children was 8.3 +/- 1.2 years and the follow-up period after the surgery was from 6 months to 10 years. Decompression operations made in the clinic have been protected by author's certificates No. 942712 and No. 1050672. The results were excellent and good in 87.8% and satisfactory in 12.2%. Decompression operations are substantiated from the pathogenetic viewpoint. They interrupt the pathologic process in the epiphysis, contribute to a rapid restoration of the femoral head, are characterized by low traumatism and may be performed simultaneously on both sides which precipitate the children's rehabilitation. The best results have been observed in the children aged 5 to 7 years and at stages I and II of the disease. The surgical treatment has allowed to reduce the terms of the treatment of the children 3 to 4-fold as compared with the conservative method.

[Perthes disease--results of a containment-oriented therapy concept]. / Morbus Perthes--Ergebnisse eines am Containment orientierten Therapiekonzepts.

INTRODUCTION: In a retrospective study a treatment concept for Perthes' disease dependent on the containment was applied. PATIENTS/METHODS: 49 hips of 41 children (9 female, 32 male) were treated between 01. 01. 1990 and 31. 12. 1995. In our concept of treatment a varus femoral osteotomy was performed in 28 cases with not contained hips or less than 4/5 coverage of the femoral head (X-ray/MRI). The other 21 well contained hips with 4/5 coverage or more were treated conservatively with physiotherapy and in case of joint effusion and pain additionally with the use of crutches (partial weight bearing) and anti-inflammatory medication. The average age in the non-operative group at the time of first investigation was 4 years and 9 months (3 y./1 m. to 7 y./1 m.) and 6 years and 3 months (4 y/2 m. to 10 y/0 m.) at our last examination (mean follow up 17.7 months, range of 6 to 72 months). At the time of indication for a varus femoral osteotomy the patients had an average age 6 years and 1 month (3 y./6 m. to 10 y./2 m.), the mean age at the last postoperative examination was 7 years and 11 months (4 y./8 m. to 12 y./5 m.) with an average follow up of 21.5 months (6 to 77 months). RESULTS: For the conservatively treated children we achieved good results (still well contained hips with 4/5 coverage, no decrease of function, no increase of pain) in 85.7% (18 of 21 cases). In 85.7% (24 of 28 cases) we found good results (well contained hips, increase of coverage, no decrease of function, no increase of pain) in the operation group. CONCLUSIONS: The presented concept of therapy in Perthes' disease was practicable for all patients and included the possibility of decision for operative or non-operative treatment. In both groups we achieved good results in 85.7% of the cases.

The results of surgical treatment for Perthes' disease.

We report the clinical and radiological results following intertrochanteric varus osteotomy and Chiari pelvic osteotomy for Perthes' disease in 70 hips with a minimum follow-up of 3 years. The indication depended on lateralization of the epiphysis of the femoral head with or without full containment in the abduction radiograph, thickening of the acetabular floor, coxa magna, and osteoarthritis. Epiphyseal quotient and sphericity showed that head deformity is mostly permanent; the acetabulum-head quotient provided good coverage. Operation in the condensation stage achieved far better results than later operations. From these and other results, the late and mild occurrence of osteoarthritis can be assumed despite deformed femoral head or acetabulum, with full coverage provided.

Innominate osteotomy for Perthes' disease.

Seventy children who underwent innominate osteotomy for Perthes' disease were reviewed. They had been subjected to this surgery because they were considered to have a poor prognosis as indicated by age, Catterall grading, and by the presence of uncovering of the femoral head. The period of follow-up ranged from 2 to 11 years and averaged 4.3 years. The clinical results were satisfactory. The radiological results were graded (using the Sundt criteria) as good in 54%, fair in 19%, and poor in 27%. Seven children developed postoperative stiffness sufficient to require hospitalization; usually these and the children with a poor result had been subjected to late surgery and had significant hip irritability or femoral head deformity preoperatively. Based on this analysis, our indication for innominate osteotomy is for a child, over the age of 6 years, with the greater part of the femoral head affected by the disease and uncovering of the femoral head. The surgery should be performed within 8 months of presentation.

[Chiari's pelvic osteotomy in the management of Perthes disease]. / Chiari-féle medenceosteotomia a Perthes-betegség kezelésében.

Authors deal, on the basis of an analysis of 3 own cases and of the literary data, with the indication of Chiari's osteotomy in Perthes' disease. It is stated that the operation is to be performed over the age of 8-9 years, in severe lesion of the femoral head, and if the femoral head is so much flattened, widened and extruded from acetabulum that it can not be centralized with varisation. The operation promotes the rebuilding of the femoral head epiphysis, the biomechanical relations are improved and the early arthrosis can be prevented.

Classificação e tratamento fisioterapêutico da doença de Legg-Calvé-Perthes: uma revisão / Classification and physical therapy of the Legg-Calvé-Perthes disease: a review

Embora a doença de Legg-Calvé-Perthes (DLCP) seja estudada desde o início do século XX, ainda hoje se discute sua etiologia. Basicamente, consiste em uma interrupção do suprimento sanguíneo que leva a isquemia na cabeça do fêmur. Em geral afeta crianças entre 2 e 12 anos, numa proporção de 4 meninos para uma menina, ocorrendo bilateralmente em 10 por cento a 20 por cento dos casos. O quadro clínico é bem definido, com dor referida no joelho ou na coxa, claudicação e perda do movimento articular do quadril. Não há consenso sobre a melhor forma de tratamento.

Although the Legg-Calvé Perthes disease (LCDP) has been studied since 1909, its obscure etiology is still under discussion. It is known that an interruption of blood supply causes ischemia of the femoral head. Typically it affects children aged 2 to 12 years old, with a male-to-female ratio of 4:1, occurring bilaterally in 10 per cent to 20 per cent of the cases. The clinical report is well defined: pain at the knee or thigh, limp, and loss of articular hip motion...